Older black HIV-positive women have more mental distress than other women with HIV, but get less help for it

A study looking at women aged over 45 living with HIV in the
UK has found that while black African and Caribbean women experience greater
social isolation and subjective mental distress than white women, they are less likely ever to
have been diagnosed with depression or have it treated.

Older African women were also more likely to experience
poverty than white or Caribbean women despite being twice as likely to have had
a university education.

Psychological distress had a potential impact on health, as
women with moderate or severe distress were 75% more likely to have missed clinic appointments
in the last year and more than twice as likely to have missed doses of their antiretroviral
therapy in the last week.

Defines who cannot take part in a research study. Eligibility criteria may include disease type and stage, other medical conditions, previous treatment history, age, and gender. For example, many trials exclude women who are pregnant, to avoid any possible danger to a baby, or people who are taking a drug that might interact with the treatment being studied.

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

These findings from the PRIME study were presented to the British HIV Association (BHIVA) conference two weeks ago by Dr Rageshri Dhairyawan of the Barts and Royal London
NHS Trust. She said that the ageing of the HIV-positive population in the UK was
particularly accentuated in women. In 2006, 14% of women with HIV in the UK were
over 45 years old and 44% under 35; in 2016, 52% were over 45 and 15% under 35.

Women with health issues were affected by both their gender
and their age, Dr Dhairyawan said. General health surveys show that being female is associated with a poorer health-related quality of life in older people;
older women have a lower socioeconomic status than men; and black and minority ethnic
(BAME) women have worse mental health as they age than white women.

Surveys of HIV-positive women in the past had found that
women were more likely to be diagnosed with depression than their male
counterparts and that depression was related to poorer HIV health outcomes. They
also found that 45% of HIV-positive women in the UK were living below the
poverty line and that poverty was also related to poorer HIV health outcomes.

So one of the objectives of the PRIME study was to explore the relationship
between ethnicity and socioeconomic status, ethnicity and mental health, and
mental health and HIV-related health in women over 45.

The PRIME study

PRIME involved three phases. First, during 2015, three focus
groups attended by 24 women explored themes and helped researchers formulate the
questionnaire for the second phase, in which 869 women aged 45-60, approached at 21 HIV
clinics across England, took part. The questionnaire covered education, employment
and immigration status as well as socioeconomic and mental health needs.

Finally, 20 women out of the 869 were selected for in-depth
interviews to further explore themes.

For the purposes of the analysis presented at BHIVA, only
women of white British, black African, and black Caribbean ethnicity were selected,
for the purposes of isolating the clearest contrasts between them. So 115 women
of other and mixed ethnicity (12% of the
total) were excluded. This left 607 black African women (72%), 71 white British women (8.4%) and 46 black Caribbean women (5.4%).

Eighty-five per cent were born outside the UK, and there
was a very wide range in the amount of time they had been in Britain. A quarter
of them had been here less than three years, while another quarter had been
here more than 43 years (in other words had moved to the UK aged 3-22).

African women were, on the whole, better educated: about
half of them had been to university compared with a quarter of both white and
Caribbean women. They were also slightly more likely to be employed. Despite
this, they were more likely to be living below the poverty line. Forty-two per
cent of African women said they did not have enough money for basic needs
compared with 36% of Caribbean women and 15% of white UK-born women.

Caribbean women were the most likely to say they felt socially isolated: 48% did, compared with 40% of African women and 25% of white
UK women.

There was striking inequality when it came to women’s mental
health needs. A quarter of all women had moderate to high levels of psychological
distress, i.e. they experienced depression, anxiety and other symptoms. Caribbean
women were more likely than average to experience these (38%) and white women
less likely (14%).

Despite this, white women were considerably more likely to
be taking anti-depressants (41% took them, compared with 28% of Caribbean women
and 26% of Africans). White women were even more likely to have ever been diagnosed with depression: 72%,
compared with 47% of Caribbean women and only 25% of African women. This shows
pretty clearly how diagnoses of mental illness do not reflect actual mental
health needs.

Poor mental health had potential physical consequences. Women
with moderate to severe psychological distress were 2.3 times more likely to have
forgotten to take at least one dose of their antiretrovirals in the last week
(33% versus 18%) and were 75% more likely to have forgotten an HIV clinic appointment
in the last year. However, this had no effect on viral suppression; 13% of
women with moderate to severe distress had a detectable viral load versus 11%
with no or mild distress, and this difference was not statistically
significant.

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